AAACN 45th Annual Conference 2020

P41 - Local Shared Governance Model Design and Implementation in Ambulatory Care Setting

Susan Ferguson, DNP, MBA, RN, CPHQ, NEA-BC | Carol Stalzer, BSN, RN, CBCN, NE-BC

Updated: 07/20/20

Background and purpose: A large ambulatory care center’s nursing and management staff recognized a mutual interest in improving communication and fostering a trusting environment. The overarching goal was to improve relationships and allow nurses to have increased involvement in decision-making. The local shared governance committee concept was proposed to accomplish the goal. Nurses in action (NIA), was developed and implemented.

Design: Committee design was developed around guiding principles, supporting inclusiveness and interprofessional membership, evidence-based practice initiatives, subject matter expert input, and metrics to define measured outcomes.

Methods: Thirteen voting and non-voting positions were created that included registered nurses, medical and nurse assistants, nurse educator, nurse manager, assistant nurse manager, clinical administrative director, and a senior administrative assistant. NIA representatives were nominated and voted onto the committee by their peers. Elected members developed a charter that defined representation, membership mix, responsibilities, and terms of service, as well as subcommittee and meeting structure. Three subcommittees, quality and safety, education, and staffing and retention, were developed to represent areas identified as the underpinning of nursing practice. Committee members are elected annually to allow full participation of all nursing staff.

Results/outcomes: At the one-year committee anniversary, 100% of staff participated in at least one subcommittee during the year. Overall, staff-driven subcommittees demonstrated key project outcomes, including the following examples:
• Quality and safety subcommittee redesigned the telephone triage script for patient calls, resulting in a decrease in the incoming call telephone abandonment rate from 23% to 4%. Other process improvement initiatives included addressing the National Patient Safety Goal NPSG.03.06.01 related to compliance with medication reconciliation and NPSG.15.01.01 related to suicide prevention. The latter project resulted in improved completion rates of a validated patient needs screening tool and appropriate intervention and referral for patients at risk for suicide.
• Education subcommittee used evidence-based practice to organize two interprofessional mock codes. This project resulted in a significant improvement in response time to emergent events and compression fraction rates during a simulated cardiac arrest. Additionally, in collaboration with nursing education, bi-annual nursing skills fairs were conducted to promote oncology nursing staff competencies. Twelve institutional specialists were selected and spoke to nursing staff on relevant nursing practice topics for continuing education credits.
• Staffing and retention subcommittee developed an expanded staffing coverage partnership model to assist with time off requests throughout the year. This staffing model also provides coverage for lunch breaks, meetings, and additional support for each other day to day. Members reviewed and approved staff time-off requests during the holiday period, resulting in 100% approval of requested time. The committee also planned and hosted six interprofessional social activities.

Implications: This progressive, local shared governance model has redistributed the center’s decision-making process. Professional empowerment was accomplished through a commitment by staff and management. Problem-solving through shared governance was shown to be an effective way to improve interprofessional relationships and nursing staff development and identify and respond to patient needs and perspectives. The NIA structure has been expanded to include advanced practice nurse representation in fiscal year 2020.

P42 - Medical Assistant Orientation with RN Mentor

Carlene Green, BSN, RN | Sarah Hart, BSN, RN | Patricia Salgueiro, BSN, RN

Updated: 07/20/20

Purpose: The medical assistant (MA) in the genitourinary (GU) clinic at a Magnet, NCI-designated comprehensive cancer center has the ability to work effectively in a team environment but can also work as a self-motivated, highly functioning individual while in the cystoscopy procedure room. These two areas of practice make the MA role in the GU clinic both dynamic and multifaceted.

In 2017, the medical assistant team began experiencing high turnover. This made it challenging for the remaining medical assistant team members to work cohesively and safely. Our aim was to elevate the role of the MA to “top of license” in order to improve job satisfaction and retention.

Description: The nurses in the GU clinic developed a MA preceptor/RN mentor program. Each newly hired MA is paired with a MA preceptor. The MA preceptor completed a GU-provided preceptor class, which included developing skills in authentic dialogue and being comfortable with discussing feedback techniques effectively. The new MA is also paired with a RN who is an accredited preceptor. This RN acts as a mentor to the new hire and as a mentor to the MA preceptor. The RN meets with each MA separately and then together as a team to foster communication, identifies goals, and provides a solid support system throughout the orientation process.

Outcome: Our MA team has developed into a strong, competent team who has become empowered to further improve their processes. Each new MA hire that was paired with an MA preceptor has remained with the team, thus reducing the high turnover rate. When the process was implemented in September 2017, the team was down to 2 MAs. Now, in November 2019, our team has grown to 9 MAs. The MAs reported feeling more confident in their role. MA retention rate increased from 36% to 73% post-RN mentor implementation. The clinic staff reports confidence in the MA skill level.

Evaluation: The development of a MA preceptor with RN mentor orientation process for new MA staff was successful. MAs who are paired with a trained MA preceptor and a trained RN mentor report feeling more empowered in their role and demonstrate that empowerment daily through their work. They have successfully started their own initiatives to improve existing processes. The MA team makes daily assignments and adjusts it according to the clinic’s daily needs. The empowerment within this MA team has a positive impact on patients, the clinic staff, and on future hires as well.

P43 - Effects of Diffusion of Essential Oils on Staff's Perceived Stress

Janet Myers, DNP, APRN, FNP/GNP-BC, ADM-BC, CDE, NE-BC

Updated: 07/20/20

Purpose (what): Anxiety and stress are common perceptions in busy, chaotic healthcare settings. Innovative strategies to promote employee wellness are crucial to satisfaction, productivity, and retention. This study's purpose was to investigate the effects of diffused essential oils on staff's perceived stress.

Relevance/significance (why): Diffusion of essential oils may elevate mood, calm senses, increase alertness, and decrease anxiety in emotionally and physically demanding work environments. Although a normal response to stress, anxiety becomes problematic when constant. In today's healthcare settings, stress is a common, inherent environmental characteristic. As an innovative intervention, essential oil diffusion may reduce stress, support employee wellness and ultimately, boost employee satisfaction and care outcomes.

Strategy/implementation/methods (how): Effects of essential oil diffusion on perceived stress was examined during a 12-week IRB approved study. Participants who consented for the study included adult male and female employees of a high-volume walk-in clinic. Perceived stress scale (PSS) evaluated perceived stress before, during and after oil diffusion. A baseline PSS survey was completed prior to the intervention. Diffusion of citrus essential oils was then started; diffusion continued for 4 weeks. The second PSS was completed in the last week of this diffusion period. Diffusion was then discontinued for 2 weeks. At the end of this period, participants completed the final PSS.

Evaluation/outcomes/results (so what): Individual PSS scores range from 0 to 40 with scores of 14 or greater equating to moderate or higher perceived stress. Participant’s median perceived stress levels showed: baseline 20; during effusion 11; and post- effusion 14.5. Data analysis revealed a 45% reduction in perceived stress when baseline results were compared to responses collected during 4 weeks of citrus oil effusion equating a statistically significant finding (p = 0.015). Following diffusion discontinuation, perceived stress levels rose by 21% confirming residual effects of the intervention. Reduction in perceived stress levels may support employee satisfaction and enhance performance and productivity.

Conclusions/implications (and now): In today's demanding care environment, aromatherapy may support employee well-being by reducing stress perception. As a component of an employee wellness initiative, this intervention rendered no adverse effects, is cost effective and continues to be a sustainable, replicable, wellness innovation.

P44 - Good Things Come to Those Who DON'T Have to Wait!

Paula Culbert, BSN

Updated: 07/15/20

Purpose (what): The goal of this project was to empower nursing and other clinic staff to come up with a solution to reduce overall patient wait time and improve clinic patient satisfaction.

Relevance/significance (why): In fiscal year 2018, the clinic ranked in the 20th percentile for wait time according to Press Ganey results. This metric combined with real-time patient feedback in clinic suggested wait time needed to be an area for focused improvement.

Strategy/implementation/methods (how): In an effort to decrease patient waiting time and improve patient satisfaction, a multidisciplinary team of nurses, dental assistants, surgeons, and administrators came together to identify barriers and form solutions. The team identified clinic templates as the root cause of the problem. The nurses vocalized that the template was built not taking patient diagnosis and complexity into consideration. The team designed a new template to strategically space out clinic appointments based on appointment type and diagnosis.

Evaluation/outcomes/results (so what): Total patient wait time was decreased an average of 20 minutes over the course of 6 months. The template redesign created clinic flow efficiencies, yielding shorter wait times for patients. Press Ganey feedback also demonstrated improvement as the percentile ranking went from the 20th percentile to 65th percentile. This increase suggested the template redesign positively impacted patient satisfaction by decreasing wait time at the clinic.

Conclusions/implications (and now): This project is an example of the power of shared governance. By including each member of the team, we received valuable insight that led to not only improved delivery of patient care, but also a more engaged team as a whole.

P45 - Medical Assistants Value in Value-Based Care

Kathy Krause, MSN, RN

Background and purpose: As we try to reign in the rising cost of health care, the fee for service model has come under great scrutiny. This payment structure has resulted in the US spending more per person on health care than any other country. The value-based payment structure, where payment is based on a set of performance measures, was introduced as a structure to reduce spending while maintaining or improving the quality of health care. A large accountable care organization in the Southwest created a central team of administrative medical assistants who focus on gathering data from disparate systems within and outside of the organization and/or contacting patients directly to satisfy quality measures.

Methods: Under nursing leadership a central population health team was created. This team consists of administrative medical assistants led by managers who are also medical assistants. Originally these medical assistants were housed in the clinic and often found themselves being pulled to perform direct patient care. In 2018, the administrative medical assistants were removed from the clinic setting and centralized allowing the organization to leverage economies of scale and to solely focus on improving quality measures.

Results: This centralized concept showed a positive impact on colorectal cancer screening, breast cancer screening, HbA1c control for diabetics, and hypertension blood pressure control quality measures. From the end of 2017 to September 2019 colorectal cancer screening increased 3.4%, breast cancer screening increased 4.6%, HbA1c control for diabetics decreased 1.8% (inverse measure) and hypertension blood pressure control increased 6.3%.

Conclusion: The value of having a centralized administrative medical assistant model is reflected in the improvement in these four quality measures. All four measures are meeting or exceeding the CMS 4 STAR rating.

P46 - A New Leadership Standard: Creating a Standardized Orientation Approach for New Nurse Managers

Karolyn Roberts, MSN, RN, CPN

Updated: 07/19/20

Updated: 07/20/20

All too often, nurse leaders are thrown into a new role and are expected to “figure it out” as they go. There is no orientation period, no mentorships, and no guidance through the learning process. In the ambulatory care setting, it can be hard simply to define what a nurse manager means.

In a vast ambulatory care service line within a large healthcare enterprise (over 80 clinics throughout the state), nurse leaders are imperative to a successful clinical environment. Recently, nursing leadership positions in this enterprise grew from 5 to 11 nurse clinical manager seniors within ambulatory care services. It was important during this influx to create a more standardized orientation approach to this essential role. Major job responsibilities for the nurse clinical manager senior include quality patient care and outcomes management, personnel and resource management, professional development, and service. Using these job responsibilities, along with orientation elements that were already in place for clinical staff, a standardized process was created.

An orientation program should socialize the new manager; they should learn about their coworkers and the organization’s culture, values, and goals. Didactic content should be supplemented with programming designed to help new managers step into their leadership role, learn necessary management skills, and cultivate an overall understanding of the institution (Conley, Branowicki, & Hanley, 2007). New nurse managers were invited to attend leadership training offered by the organization, as well as a clinical orientation day that introduced them to ambulatory care and nursing services. They participated in a preceptorship, both with other nurse clinical manager seniors and their non-clinical practice manager counterparts within the clinic. They shadowed individuals in various clinical roles to learn day-by-day processes and identify existing workflows and areas for change and improvement.

Competencies are an important aspect of orientation because they assess the critical thinking, technical, and interpersonal skills of the new team member. Initial competencies are based on core job functions, frequently used functions, high-risk functions, and the intended essence of the job (Wright, 2005). In the absence of an existing nurse clinical manager senior competency, one was created from portions of the current nursing competencies with the addition of essential functions from the role’s major job responsibilities. The various preceptors working with the new nurse manager help to complete competencies during the orientation period.

In addition to preceptorships and competencies, the new nurse managers receive a detailed checklist of requirements (both classroom and online education), a calendar of their orientation schedule, including scheduled classes and time with various preceptors, and progress meetings with a senior nurse leader and staff development specialist. In a survey of the new managers, 75% described these elements as “very helpful.”

References
1. Conley, S.B., Branowicki, P. & Hanley, D. (2007). Nursing leadership orientation: A competency and preceptor model to facilitate new leader success. The Journal of Nursing Administration, 37(11), pp 491-498
2. Wright, D. (2005). The ultimate guide to competency assessment (3rd ed.). Minneapolis, MN: Creative Health Care Management, Inc.

P47 - An Exceptional Case of Undergraduate Student Nurse Learning in Primary Care

Patricia A. Barfield, PhD, RN, PMHNP-BC | Robin Claudson, MSN, RN

Updated: 07/20/20

Purpose: To explore the contextual and relational elements in one case of undergraduate student nurse learning in primary care.

Background/significance: Healthcare reform, changing demographics, and the swell of chronic disease have amplified the nation’s healthcare workforce demands in primary care. Nursing is responding to the call, and the American Academy of Ambulatory Nursing (AAACN) is leading the charge to redesign the role of registered nurses (RNs) in ambulatory and primary care settings (AAACN, 2017). The AAACN’s transformational leadership in expanding the role of RNs urges schools of nursing and nurse educators to reexamine curricula and redesign clinical learning experiences to prepare students to lead and to practice at the top of their license across the continuum of care. Preparing student nurses to be “practice ready” RNs in primary care will require, in most instances, strategic curricula revision and development of dynamic academic-practice partnerships.

When one student learning experience stands out there is a curiosity and desire to understand why and how this particular case may be different. This presentation will highlight the critical contextual and relational elements in one exceptional case of undergraduate student nurse learning in primary care to “grab the nuances of real-life experience” (Sandelowski, 1996, p. 527). The case was situated within a larger primary care training program and research study aimed at educating undergraduate nursing students, nurses, and community partners about the role of RNs in primary care.

Methods: A single-case study design was used to explore the contextual and relational elements in one exceptional case of undergraduate student nurse learning in primary care. The case comprised the student, faculty, curricula, course assignment(s), and academic-practice partner model of care and preceptor. Data were collected via interviews, survey, and written documents and analyzed descriptively. A case study approach is appropriate when the focus of inquiry is to answer why or how questions and when the contextual conditions are relevant to the phenomena of interest (Yin & Campbell, 2018).

Results: Spiraling curricula (e.g. health promotion, population health) introduced the student to the basic concepts of promoting and managing health across the lifespan and care continuum. Community-based assignments (e.g., community assessment, service-learning projects) promoted the application of knowledge and the development of community-based nursing skills in non-traditional settings. Faculty developed and delivered concept-based learning activities (CBLAs) targeting primary care concepts (e.g., health equity, population health management) deepened context-specific knowledge. A clinical learning experience where the model of care supports top of license practice revealed in “real time” the many roles of RNs in primary care (e.g., triage, referral, complex care coordination/management, transitional care management, interprofessional networking, patient advocacy across different systems) and mobilized the preceptors’ desire to teach, lead, and learn.

Conclusion/implications: The synergistic combination of spiraling curricula, community-based assignments, focused CBLAs, and academic-practice partners that support top of license RN practice enhanced student learning beyond the “usual” and provided valuable input to a training program and research study aimed at educating undergraduate nursing students, nurses, and community partners about the role of RNs in primary care.

P48 - Clinical Mentoring Academy for Primary Care Nurse Mentors

Shawona Daniel, PhD, RN, CRNP | Alveta Reese, MSN, RN, OCN

Updated: 07/20/20

Registered nurses in the primary care setting are under-represented and are vital to high-quality, cost-effective management of populations with complex health conditions.1 Increasing numbers of bachelor-prepared nurses in primary and community-based settings has the potential to improve patient outcomes. However, the absence of clear career pathways and inconsistent role definitions is a barrier to attracting and retaining new nurses in primary care.2 A key factor in increasing new nurses’ consideration of primary care is providing meaningful clinical placements in these areas. Clinical placements have been shown to be a predictive element in students’ decision to enter primary health care and those who participate in evocative primary care placements during their undergraduate career are more likely to identify intent to work in a primary care setting.3

Providing students with a positive clinical learning environment, including supportive nurse mentors, assists in the development of positive attitudes and decisions to work in primary care.3 A positive clinical experience is dependent upon a successful preceptor experience, adequate preceptor role education, and institutional support.4 To facilitate the clinical experience of students selected to participate in a registered nurse primary care (RNPC) scholars program, nursing faculty developed and implemented a clinical mentoring academy that provides training to mentors who would engage students in the primary care setting. The clinical mentoring academy consisted of a one-day workshop that allowed presentation of primary care mentor specific concepts shown to improve nursing retention, including socialization into the organization and stress management.5 The curriculum was designed to be comprehensive with three distinct modules: 1) the basics of primary care, 2) interprofessional education and collaborative practice, and 3) the primary care registered nurse mentor roles and responsibilities. Concepts of resiliency were threaded through each module, as evidence suggests that integrating resilience in undergraduate education is essential for preparing students to persevere through adversities while maintaining physical, mental, and emotional health during their career.6 Content captured in these modules included primary care nurse competencies, social determinants of health, application of interprofessional collaborative practice, mentoring students in primary care settings, and navigating the mentor-mentee relationship. The clinical mentoring academy engaged mentors in activities designed to capture the cognitive, psychomotor, and affective domains of learning. Clinical mentors participated in an interactive game focused on identifying social determinants of health and appropriate interventions at varying levels of prevention. A culminating activity required mentors to exam case studies of difficult mentor-mentee scenarios in primary care and discuss their thoughts as a mentor and from the perspective of the student.
Clinical mentors reported feeling more connected to the goals of the RNPC scholars program following completion of the academy. They believed that they were better prepared to foster an effective learning environment and promote resiliency in their care settings. The outcomes of this clinical mentoring academy support a collaborative effort from primary health care nurses, health professionals, and academic institutions to attract and retain new graduate nurses to primary health care.

P49 - Diabetes Screening Alignment

Rachel Blackburn, MA, RN-BC | Shelly Johnson, BSN, RNC

Updated: 07/15/20

Standardizing guidelines could save money, reduce risk and harm, and provide simpler means to measure outcomes. It takes effort for providers to agree on a standard. Literature review, collaboration, and persistent nurses informed Providence women's clinics to agree on one test despite no conclusive recommendation on which gestational diabetes screening method is best (Caughey, A. & Turrentine M., 2108). Though it took 8 years, clinicians worked hard to agree on a measure that would save time and money.

Reference
1. Caughey, A., & Turrentine, M. Acog practice bulletin: Clinical management guidelines for obstetrician-gynecologists. The American College of Obstetricians and Gynecologists, 131(2).

P50 - Professional Development Needs of Community-Based Primary Care Nurses: An Assessment to Support Full Scope of License Practice

Chimora Amobi, MD, MPH | JoAnna Hillman, MPH | Quyen Phan, DNP, APRN, FNP-BC, Assistant Clinical Professor, Emory University

Updated: 07/19/20

Objective: Preparing community-based primary care registered nurses (RNs) to practice to the full scope of their license will require a comprehensive professional development approach. The Community-Academic Partnership for Primary Care Transformation (CAPACITY) project, funded by the Health Resources & Services Administration involves an academic-clinical partnership between a research university, and a federally qualified health center (FQHC) in an urban setting serving vulnerable populations in Atlanta, GA. In this presentation, we describe how we are leveraging this partnership to create a professional development program customized to support expanding nursing practice of RNs to the full scope of license within a primary care setting.

Approach: To guide the focus of the professional development program for RNs, a needs assessment was conducted to identify areas of interest and importance for practicing to the full scope of their nursing license. A mixed-methods and phased approach was used for this needs assessment. The needs assessment design included an online survey and an in-person discussion (similar to a focus group) held with registered nurses (RNs) at the FQHC. The needs assessment was built using the patient-centered medical home assessment (PCMH-A) as the foundation and was supplemented by additional questions regarding soft skills and the organizational and environmental context of the setting. The sample included 11 FQHC clinic RNs, representing three FQHC clinic locations.

Outcomes: The results indicated the areas where the FQHC clinic would benefit from professional development in order for RNs to expand their nursing practice. Of the eight PCMH-A domains, “quality improvement strategy” (mean=3.52) was the highest scoring domain, and “empanelment” (mean=2.73) was the lowest scoring domain. Other domains identified for improvement were “continuous and team-based healing relationships” (mean=3.12), “organized, evidence-based care” (mean=3.13), and “enhanced access” (mean=3.13). When asked about topic areas to gain more knowledge and skill, participants prioritized substance abuse, behavioral health, diabetes/prediabetes, dermatology, and wound care. Lastly, participants identified managing complexity (64%), managing conflict (55%), and communicating effectively (55%), as areas where they need further improvement. A curriculum model for the professional development program has been developed based on these results and initial deployment of these modules began in April 2019.

References:
1. American Academy of Ambulatory Care Nursing. (2010). The role of the registered nurse in ambulatory care position statement.
2. Bauer, L. & Bodenheimer, T. (2017). Expanded roles of registered nurses in primary care delivery of the future. Nursing Outlook, 65, 624-632. doi: 10.1016/ j.outlook.2017.03.2011.
3. Bodenheimer, T. &, Bauer, L. (2017). The Future of Primary Care: Enhancing the registered nurse role. In Bodenheimer, T. & Mason D. (Eds.), Registered Nurses: Partners in Transforming Primary Care: Proceedings of a Conference on Preparing Registered Nurses for Enhanced Roles in Primary Care (pp. 57-86). New York, NY: Josiah Macy Jr. Foundation.
4. Daniel, D. M., Wagner, E. H., Coleman, K., Schaefer, J. K., Austin, B. T., Abrams, M. K., ... & Sugarman, J. R. (2013). Assessing Progress toward Becoming a Patient‐Centered Medical Home: An Assessment Tool for Practice Transformation. Health services research, 48(6pt1), 1879-1897.